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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 345003013
Report Date: 10/02/2024
Date Signed: 12/03/2024 10:54:43 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/06/2024 and conducted by Evaluator DeAnna Williams-Lyons
PUBLIC
COMPLAINT CONTROL NUMBER: 59-AS-20240906113641
FACILITY NAME:ANGELS ASSISTED LIVING,INC.FACILITY NUMBER:
345003013
ADMINISTRATOR:BHATIA, SIMRANJITFACILITY TYPE:
740
ADDRESS:1526 CRESTMONT DRTELEPHONE:
(916) 841-9449
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:6CENSUS: 5DATE:
10/02/2024
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Michelle Fraunhoffer, CaregiverTIME COMPLETED:
12:21 PM
ALLEGATION(S):
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Licensee does not ensure that staff have a criminal clearance
INVESTIGATION FINDINGS:
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Amended to make Public: On October 2, 2024, Licensing Program Analyst (LPA) De Anna Williams-Lyons arrived unannounced to deliver findings for complaint # 59-AS-20240906113641. LPA met with Michelle Fraunhoffer, Caregiver, and informed her the reason for the visit.

The Department received a complaint alleging the Licensee does not ensure that staff have a criminal clearance, Licensee does not ensure that staff have a medical clearance, and Licensee did not report an incident to the appropriate parties.

LPA investigated the complaint by reviewing resident and facility files and conducting interviews with residents and staff. LPA also obtained staff schedules and rosters and other documentation pertinent to the complaint. LPA reviewed the facility’s active employee roster. On the active roster, there was 15 potential staff that could be hired. The facility has employed 7 out of the 15 on the list. The 7 employees hired had criminal background clearances from the department in their employee file. Licensee stated only those that pass the Criminal Background Clearance will be considered for employment. Allegation Unfounded.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/06/2024 and conducted by Evaluator DeAnna Williams-Lyons
COMPLAINT CONTROL NUMBER: 59-AS-20240906113641

FACILITY NAME:ANGELS ASSISTED LIVING,INC.FACILITY NUMBER:
345003013
ADMINISTRATOR:BHATIA, SIMRANJITFACILITY TYPE:
740
ADDRESS:1526 CRESTMONT DRTELEPHONE:
(916) 841-9449
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:6CENSUS: 5DATE:
10/02/2024
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Michelle Fraunhoffer, CaregiverTIME COMPLETED:
12:21 PM
ALLEGATION(S):
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9
Licensee did not report an incident to the appropriate parties
INVESTIGATION FINDINGS:
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Regarding the allegation that Licensee did not report an incident to the appropriate parties; a witness reported to the licensee, another staff was taking drugs and hallucinating. The witness call 911. According to the witness, 911 sent the police and not the ambulance. The witness also stated the police arrested the employee at the facility for two active arrest warrants and was on probation. The licensee stated the incident never happened, and it is all false. Licensee stated no police ever came to the house and arrested staff. Licensee says when she arrived at the facility, there was no police, there was no report or report number left at the facility by the police. Licensee also states the person that was supposed to have been arrested, came to the facility the next morning to check on her application. Licensee stated, “If that person was arrested from the facility with 2 active arrest warrants and on probation, that person would not have been at the facility at 8am to check on their application.” When interviewed, none of the residents knew anything about the incident and said no police has been to the house. ALLEGATION UNSUBSTANSTIATED, meaning, although the violation may have happened, or is valid, there’s not enough preponderance of evidence to prove it did or did not happen.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/06/2024 and conducted by Evaluator DeAnna Williams-Lyons
COMPLAINT CONTROL NUMBER: 59-AS-20240906113641

FACILITY NAME:ANGELS ASSISTED LIVING,INC.FACILITY NUMBER:
345003013
ADMINISTRATOR:BHATIA, SIMRANJITFACILITY TYPE:
740
ADDRESS:1526 CRESTMONT DRTELEPHONE:
(916) 841-9449
CITY:ROSEVILLESTATE: CAZIP CODE:
95661
CAPACITY:6CENSUS: 5DATE:
10/02/2024
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Michelle Fraunhoffer, CaregiverTIME COMPLETED:
12:21 PM
ALLEGATION(S):
1
2
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9
Licensee does not ensure that staff have a medical clearance.
INVESTIGATION FINDINGS:
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Regarding the allegation that Licensee does not ensure that staff have a medical clearances; the employee files since licensure were reviewed by LPA and out of the 7 staff hired, 1 employee did not have medical clearance or a Health Screening. ALLEGATION SUBSTANTIATED meaning, the preponderance of evidence standards has been met. The deficiency will be cited.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D during this visit. Exit interview held, Appeal Rights discussed, copy of report given.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 59-AS-20240906113641
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ANGELS ASSISTED LIVING,INC.
FACILITY NUMBER: 345003013
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/02/2024
Section Cited
CCR
47411(f)
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47411(f) Personnel Requirements
All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray
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Licensee shall ensure staff employeed has a Health Screening Prior to working at the facility. Licensee shall document why it is important to ensure this requirement and submit to LPA no later than 10/15/2024.
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or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. Based on interviews conducted and records reviewed, this requirement was not met as evident based on facility didn't ensure staff had a Health Screening prior to working at facility, which poses a potential health, safety, and personal rights risk to the residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4